Basic Information
| Provider Information | |||||||||
| NPI: | 1437351178 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SIMOYAN | ||||||||
| FirstName: | OLAPEJU | ||||||||
| MiddleName: | MODUPEOLA | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD, MPH, BDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 MADISON AVE | ||||||||
| Address2: | |||||||||
| City: | SCRANTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 185102401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5703432383 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1020 W LACKAWANNA AVE | ||||||||
| Address2: | |||||||||
| City: | SCRANTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 185042052 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5708462720 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2007 | ||||||||
| LastUpdateDate: | 04/20/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD436535 | PA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1025945990004 | 05 | PA | MEDICAID |